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Presenter: Ask about allergies before performing injections
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ATLANTA – Optometrists are permitted to perform injections in 22 states for anaphylaxis and in 14 states for varying degrees of diagnostic and therapeutic use, Brad Sutton, OD, FAAO, reported here at SECO. However, query patients regarding allergies before performing any injections, he said, and always be ready with your EpiPen.
In a course sponsored, in part, by Primary Care Optometry News, Sutton reviewed indications, contraindications and technique for subcutaneous, intramuscular (IM), intravenous (IV), periocular and intraocular injections.
He noted that injections are now a permanent part of the National Board of Examiners in Optometry exam. He said clinicians will be tested on sterile technique for IM and IV injection with model arm pads.
The most common subcutaneous injection is insulin, Sutton said, which is typically administered in the thigh, back of the arm and abdomen.
“The objective of subcutaneous injections is for them to be absorbed slowly,” he said. “You want small needles; anesthetics are delivered this way. You don’t want a medication that you need a large dose of or something that’s irritating, because it’s right below the skin and will stay there a while.”
Intramuscular injections are performed in the deltoid or the gluteus muscle.
“The idea behind IM injections is that the onset of action is much more rapid because it’s a more vascular tissue,” Sutton said. “We want this for concentrated substances, and we use a longer, thicker needle.”
He noted a potential challenge when using an EpiPen (epinephrine injection, Mylan), which is administered intramuscularly.
“The manufacturer has not changed those pens in many years, and so many people are significantly overweight and they have problems getting that EpiPen down into the tissue,” he said. “It’s just going into subcutaneous fat and doesn’t get absorbed quickly enough to save them from an anaphylactic response.”
Intravenous injection is used with indocyanine green (ICG) angiography, intravenous fluorescein angiography and laser-assisted macular surgery.
“Definitely have your EpiPen handy, because any allergic response will happen quickly,” he said.
One of the most commonly used periocular injections in optometry is intralesional injection of chalazia, Sutton said, and second would be pyogenic granuloma. He typically uses Kenalog (triamcinolone acetate, Bristol-Myers Squibb) 10 mg/mL or 40 mg/mL or dexamethasone 2 mg/mL or 4 mg/mL.
“I prefer longer-lasting Kenalog for chalazion,” he said.
“The biggest worry with this type of injection is increased IOP with steroids and allergic response,” he said. “The IOP can go very high, and it can be delayed weeks or months after the injection.”
Sutton said that a number of glaucoma medications in the development pipeline are designed to be administered via sub-Tenon’s injection.
“Intravitreal injections are generally not performed by ODs,” Sutton said. “But you might do anesthetic application if you remove lumps and bumps, in a peribulbar block fashion where you block the entire lid you’re working on.”
Specialty uses include botulinum toxin for hemifacial spasm, blepharospasm and occasionally for strabismus.
Intravitreal injections of bevacizumab and ranibizumab are commonly used by ophthalmologists for macular edema and choroidal neovascularization.
Sutton said a study was published in Eye in 2014 where nurse practitioners in England administered these injections.
“Out of 4,000 shots, the only complication was subconjunctival hemorrhage in 5.7%,” Sutton said. “I would argue that if nurse practitioners can do it, there’s no reason why we can’t do it in the right setting.” – by Nancy Hemphill, ELS, FAAO
Disclosure: Sutton reported no relevant financial disclosures.
Reference:
Sutton B. Overview of injections in eye care.